Cystoscopy for uncomplicated lower urinary tract symptoms
Best Practice Guidance
Cystoscopy is a diagnostic procedure used to examine the lining of the bladder and urethra. Either a rigid or flexible endoscope may be used, under general or local anaesthesia, respectively. Rigid cystoscopy is undertaken when flexible cystoscopy offers insufficiently clear views, or when biopsy is indicated.
Cystoscopy can cause temporary discomfort, occasionally pain and haematuria and is associated with a small risk of infection.
In the context of male lower urinary tract symptoms (LUTS), cystoscopy may offer indirect evidence regarding an underlying cause (commonly prostatic enlargement, for example).
This guidance applies to male adults aged 19 years and over.
Assessment of men with LUTS should focus initially on a thorough history and examination, complemented by use of a frequency – volume chart, urine dipstick analysis and International Prostate Symptom Score where appropriate. This assessment may be initiated in primary care settings.
Specialist assessment should also incorporate a measurement of flow rate and post void residual volume.
Cystoscopy should be offered to men with LUTS only when clinically indicated, for example, in the presence of the following features from their history:
- Recurrent infection
- Sterile pyuria
- Profound symptoms
Additional contextual information may also inform clinical decision-making around the use of cystoscopy in men with LUTS. Such factors might include, but not be limited to:
- Smoking history
- Travel or occupational history suggesting a high risk of malignancy
- Previous surgery.
Other adjunct investigations may become necessary in specific circumstances and are dealt with in the NICE guideline. It may be reasonable to undertake flexible cystoscopy before doing some urological surgical interventions.
Rationale for recommendation
In the context of male lower urinary tract symptoms (LUTS), cystoscopy may offer indirect evidence regarding an underlying cause (commonly prostatic enlargement, for example). However, no evidence was discovered in preparing NICE guideline CG97 to suggest any benefit, in terms of outcome, related to performing cystoscopy in men with uncomplicated LUTS (i.e. LUTS with no clinical evidence of underlying bladder pathology). The consensus opinion of the NICE guideline development group therefore aligned with the position that unless likely to uncover other pathology, cystoscopy should not be performed in men presenting with LUTS.
The European Association of Urology guideline on the management of nonneurogenic male LUTS summarises evidence demonstrating a lack of clear correlation between findings on cystoscopy and findings on investigations into bladder function (urodynamic assessment).
There is no specific EBI patient guidance for this intervention.
However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.
Further information on patient involvement in EBI can be found on the EBI for patients section.
WHEN LEFT(der.Spell_Dominant_Procedure,4) in ('M455','M458','M459’) AND apcs.sex=1 AND not (apcs.der_diagnosis_all like '%F171%’ OR apcs.der_diagnosis_all like '%N390%’ OR apcs.der_diagnosis_all like '%R31%’ OR apcs.der_diagnosis_all like '%R398%’) AND apcs.Der_Procedure_All not like '%M45[1-4]%’ AND isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120 AND APCS.Admission_Method not like ('2%’) THEN '2H_cystoscopy_UTI'
Procedure codes (OPCS)
M455 Diagnostic endoscopic examination of bladder using rigid cystoscope
M458 Other specified diagnostic endoscopic examination of bladder
M459 Unspecified diagnostic endoscopic examination of bladder
M451 Diagnostic endoscopic examination of bladder and biopsy of lesion of bladder NEC
M452 Diagnostic endoscopic examination of bladder and biopsy of lesion of prostate NEC
M453 Diagnostic endoscopic examination of bladder and biopsy of lesion of bladder using rigid cystoscope
M454 Diagnostic endoscopic examination of bladder and biopsy of lesion of prostate using rigid cystoscope
Diagnosis codes (ICD)
F171 Mental and behavioural disorders due to use of tobacco – Harmful use
N390 Urinary tract infection, site not specified
R31X Unspecified haematuria
R398 Other and unspecified symptoms and signs involving the urinary system
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and apcs.der_diagnosis_all not like '%D0%' and apcs.der_diagnosis_all not like '%D3%' and apcs.der_diagnosis_all not like '%D4%’
This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
— Private Appointment Exclusion
- NICE Clinical guideline (2010) Lower urinary tract symptoms in men: management [CG97] .
- European Association of Urology. Management of non-neurogenic male LUTS
- Shoukry, I., et al. Role of uroflowmetry in the assessment of lower urinary tract obstruction in adult males. Br J Urol, 1975. 47: 559 DOI: 10.1111/j.1464-410x.1975.tb06261.x
- Anikwe, R.M. Correlations between clinical findings and urinary flow rate in benign prostatic hypertrophy. Int Surg, 1976. 61: 39
- el Din, K.E., et al. The correlation between bladder outlet obstruction and lower urinary tract symptoms as measured by the international prostate symptom score. J Urol, 1996. 156: 102 DOI: 10.1097/00005392-199603000-00061
How up to date is this information?
Last revised December 2023
December 2023 - Coding updated. August 2022 - Coding updated